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Case report

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Rothia aeria endocarditis in a patient with a bicuspid aortic valve: case report

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A.C. Nicodemo a,∗ , L.G. Gonc¸alves a , F.C.A. Odongo a , M.D.V. Martino c , J.L.M. Sampaio b

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Department of Infectious and Parasitic Diseases, University of São Paulo, Medical School, São Paulo, Brazil Department of Clinical Analysis, School of Pharmacy, University of São Paulo, São Paulo, Brazil Microbiology Laboratory, Hospital Israelita Albert Einstein, São Paulo, Brazil

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a r t i c l e

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a b s t r a c t

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Article history:

Rothia aeria is an uncommon pathogen mainly associated with endocarditis in case reports.

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Received 11 April 2014

In previous reports, endocarditis by R. aeria was complicated by central nervous system

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Accepted 6 May 2014

embolization. In the case we report herein, endocarditis by R. aeria was diagnosed after acute

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Available online xxx

self-limited diarrhea. In addition to the common translocation of R. aeria from the oral cavity, we hypothesize the possibility of intestinal translocation. Matrix-assisted laser desorption

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Keywords:

ionization-time of flight mass spectrometry and genetic sequencing are important tools that

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Rothia aeria

can contribute to early and more accurate etiologic diagnosis of severe infections caused by

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Endocarditis

Gram-positive rods.

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Intestinal translocation

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Molecular diagnosis

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© 2014 Published by Elsevier Editora Ltda.

Introduction

Case report

Rothia is a genus of Gram-positive, non-acid-fast bacteria proposed by George and Brown in 1967. This genus grows well under aerobic conditions on BHI agar. Young colonies are smooth, tending to become rough, dry, convex and adherent to the culture medium when mature. The bacterial cells can appear coccoid, cocco-bacillary or filamentous. The species Rothia aeria was characterized in 2004 after isolation from the Russian space station Mir. Initially, it was known as Rothia dentocariosa genomovar II.1 R. aeria is known to colonize human oral cavity, but has also been identified in duodenal biopsy as a colonizer of the upper gastrointestinal tract.2 To our knowledge, this is the sixth case report of endocarditis by R. aeria.

A previously healthy 25-year-old man presented with acute self-limited diarrhea for three days after a trip to Salvador, Brazil. After diarrhea resolution, he started to experience daily fever spikes. He visited a physician who prescribed levofloxacin 500 mg daily for seven days with symptom improvement. However, fever recurred after stopping levofloxacin. He sought further medical assistance on the 4th week of illness. Examination was remarkable for a grade 2/6 aortic murmur and an enlarged spleen. Transesophageal echocardiography showed a bicuspid aortic valve with significant regurgitation and a vegetation of 4 mm. Two blood culture samples obtained from different venous sites both yielded Gram-positive rods.



Corresponding author. E-mail addresses: ac [email protected], [email protected] (A.C. Nicodemo). http://dx.doi.org/10.1016/j.bjid.2014.05.001 1413-8670/© 2014 Published by Elsevier Editora Ltda.

Please cite this article in press as: Nicodemo AC, et al. Rothia aeria endocarditis in a patient with a bicuspid aortic valve: case report. Braz J Infect BJID 346 1–4 Dis. 2014. http://dx.doi.org/10.1016/j.bjid.2014.05.001

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Table 1 – Summarized case reports of Rothia aeria clinical infections. Author/Year

Hiraiwa T et al. Japan. 2013

44 45 46 47 48 49 50 51 52 53 54

Reference

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Disease

Endocarditis (positive aerobic blood cultures)

Thiyagarajan A et al. UK. 2013

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Endocarditis (positive aerobic blood cultures)

Crowe A et al. Australia. 2013

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Endocarditis (positive aerobic blood cultures)

Age

Risk factor/ chronic dz Renal transplantation due to renal cell carcinoma on tacrolimus and everolimus use Dental caries and gingivitis Not reported on abstract

Ex-smoker Hypertension

63 years

Treatment

Penicillin G 8 weeks

Outcome

Brain septic embolization as complication Survived

61 years

Benzylpenicillin + Rifampicin + Gentamicin

48 years

Benzylpenicillin + Gentamicin 2 weeks; Benzylpenicillin + Ceftriaxone 8 weeks; Rifampicin + Ciprofloxacin 12 weeks

Brain septic embolization as complication Survived Brain septic embolization as complication Spleen, left kidney infarction Right renal artery and hepatic artery aneurysms Survived Died on 15th day of hospital admission of brainstem hemorrhagic complication Died of hemorrhagic complication

Tarumoto N et al. Japan. 2012

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Endocarditis

Smoking

40 years

Ceftriaxone + Gentamicin

Holleran K and Rasiah S. Australia. 2012 Falcone EL et al. USA. 2012

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Endocarditis

Not reported

48 years

Not reported

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Neck abscess

18 years

Amoxicillinprobenecid for 2 months

Survived

Verrall AJ et al. New Zealand. 2010

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Dental decay and shoulder articulation infection Acute bronchitis

X-linked chronic granulomatous disease and prednisone use for colitis Dental caries Methotrexate and hydrocortisone for rheumatoid arthritis Anti-TNF therapy (etanercept) for rheumatoid arthritis Steroid and azathioprine therapy for neurosarcoidosis Mother underwent decayed tooth extraction 4 days before delivery

88 years

Penicillin for 14 days

Survived

66 years

Amoxicillin + Moxifloxacin for 1 week Penicillin for 8 weeks + Amoxicilin for 5 months Ampicillin + Cefotaxime for 11 days

Survived

Michon J et al. France. 2010

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Hiyamuta H et al. Japan. 2010

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Pulmonary cavitary infection

Monju A et al. Japan. 2009

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Neonatal sepsis

Empirical treatment with ampicillin 2 g q4h and vancomycin, initial loading dose of 25 mg/kg and maintenance dose of 15 mg/kg q12h, was started due to initial organism identification as Rothia spp. After complete identification of the bacteria as R. aeria, vancomycin was discontinued. Ampicillin was maintained because antimicrobial susceptibility test showed a 0.032 mcg/mL minimum inhibitory concentration (MIC) for penicillin. This isolate was susceptible to all of the tested antimicrobials (ciprofloxacin 1 mcg/mL, gentamicin 1.5 mcg/mL, linezolid 0.38 mcg/mL, and vancomycin 1.5 mcg/mL), except for daptomycin with a MIC of 6.0 ␮g/mL.

53 years

3 h of life

Survived

Survived

Endocarditis treatment was uneventful. The patient progressively improved, fever completely resolved and inflammation markers normalized. Ampicillin was stopped after five weeks and follow-up echocardiography revealed complete resolution of the vegetation.

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Discussion Rothia is a genus of Gram-positive, non-acid-fast bacteria proposed by George and Brown in 1967. This genus grows well

Please cite this article in press as: Nicodemo AC, et al. Rothia aeria endocarditis in a patient with a bicuspid aortic valve: case report. Braz J Infect BJID 346 1–4 Dis. 2014. http://dx.doi.org/10.1016/j.bjid.2014.05.001

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under aerobic conditions on BHI agar. Young colonies are smooth, tending to become rough, dry, convex and adherent 64 to the culture medium when mature. The bacterial cells can 65 appear coccoid, cocco-bacillary or filamentous. The species R. 66 aeria was characterized in 2004 after isolation from the Rus67 sian space station Mir. Initially, it was known as R. dentocariosa 68 genomovar II.1 R. aeria is known to colonize human oral cavity, 69 but has also been identified in duodenal biopsy as a colonizer 70 of the upper gastrointestinal tract.2 To our knowledge, this is 71 the sixth case report of endocarditis by R. aeria. 72 After a literature search of R. aeria infections, our case is 73 the eleventh case report of clinical infection and the sixth 74 case report of endocarditis.3–12 The case reports include five 75 cases of endocarditis,3–7 one case of neck abscess,8 one case 76 of shoulder joint infection9 ; two cases of lung infection10,11 ; 77 and one case of neonatal sepsis,12 as shown in Table 1. Three 78 cases had a previous history of dental caries and the neona79 tal sepsis occurred after maternal tooth extraction.3–9 These 80 previous case reports show that R. aeria is capable of infecting 81 various body sites and also show that infection by this agent 82 is probably more in immunocompromised patients, as some 83 patients were on immunosuppressive medications.3,8–11 All 84 five case reports of endocarditis by R. aeria had central nervous 85 system embolic complications; two cases had fatal central ner86 vous system hemorrhage.3–7 In one recent case report of mitral 87 valve endocarditis with confirmed brain septic emboli, prompt 88 antibiotic treatment and urgent metallic mitral valve replace89 ment may have prevented further complications and allowed 90 the patient to be successfully discharged on outpatient antibi91 otic treatment.4 So far, our case is the only R. aeria endocarditis 92 infection where embolic complications have not occurred. 93 R. aeria and R. dentocariosa are both known to colonize 94 unhealthy oral cavities. They may then translocate into blood 95 and disseminate, causing endocarditis or other infection in 96 individuals at risk.3,9,12 Our patient had excellent dental 97 hygiene and had not been submitted to any dental procedures 98 in the last six months. Some studies have suggested coloniza99 tion of the small intestine (duodenum) by this bacteria and 100 its role in gluten metabolism.2 Therefore, considering that 101 this patient initially presented with acute self-limited diar102 rhea, we hypothesized that endocarditis may have resulted 103 from intestinal translocation and infection of the thickened 104 bicuspid aortic valve. 105 In our clinical case, initial identification after blood culture 106 on agar revealed a Gram-positive rod, which was identified by 107 Vitek 2 as R. aeria. Since R. aeria is a rarely reported human 108 pathogen and due to commonly inconclusive results of the 109 biochemical identification of Gram-positive rods, it was rea110 sonable to confirm diagnosis by molecular methods. Gene 111 sequence analysis by MicroSeq Library identified R. aeria with 112 a 99.98% match. Additionally, the sequence was compared to 113 those of other Rothia species available at the GenBank database 114 – http://www.bacterio.net/qr/rothia.html.13 The highest simi115 larity index (99.77%) was observed with a deposit pertaining 116 to the type strain R. aeria (GenBank assession CP001368.1). 117 The same result was obtained when performing a local BLAST 118 Q3 using the Rothia species 16S rRNA nucleotide sequence. The 119 second highest similarity (98.62%) was observed with the Gen120 Bank deposit CP002280.1, corresponding to the type strain 121 of R. dentocariosa. Early identification of R. aeria can also be 62 63

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achieved using matrix-assisted laser desorption ionizationtime of flight mass spectrometry (MALDI-TOF MS).5,8 Treatment of R. aeria infection is variable and dependent on the assisting physicians and susceptibility tests, as we have seen from the case reports (Table 1). All case report isolates were shown to be sensitive to penicillins, which seemed to be the drugs of choice in some of the cases.3,8–11 One case was initially treated with a combination therapy of benzylpenicillin, rifampicin and gentamicin. Our patient promptly responded to treatment with ampicillin after antibiotic susceptibility results according to the Clinical and Laboratory Standards Institute (CLSI) guidelines.14 In conclusion, we summon attention to the seemingly high embolic complications of endocarditis by R. aeria. Therefore, R. aeria endocarditis should be promptly managed with adequate antibiotic treatment and surgical valve replacement whenever necessary in order to improve patient prognosis. In addition to common translocation of R. aeria from the oral cavity, we hypothesize the possibility of intestinal translocation. MALDITOF MS and genetic sequencing are important tools that can contribute to early and more accurate etiologic diagnosis of severe infections caused by Gram-positive rods.

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Funding This work did not receive any funding.

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Conflicts of interest The corresponding author states that there is no conflict of interest.

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1. Ying L, Yoshiaki K, Nagatoshi F, et al. Rothia aeria sp. nov., Rhodococcus baikonurensis sp. nov. and Arthrobacter russicus sp. nov., isolated from air in the Russian space laboratory Mir. Int J Syst Evol Microbiol. 2004;54:827–35. 2. Maram Z, Guoxian W, Floyd D, et al. Identification of Rothia bacteria as gluten-degrading natural colonizers of the upper gastro-intestinal tract. PLoS ONE. 2011;6:e24455. 3. Hiraiwa T, Izumi M. Successful management of Rothia aeria endocarditis with renal transplantation patient: a case report. Eur J Intern Med. 2013;24 Suppl. 1:e204. 4. Thiyagarajan A, Balendra A, Hillier D, et al. The first report of survival post Rothia aeria endocarditis. BMJ Case Rep. 2013 Q4 [abstract]. 5. Crowe A, Ding N, Yong E, et al. Rothia aeria mitral valve endocarditis complicated by multiple mycotic aneurysms: laboratory identification expedited using MALDI-TOF MS. Infection. 2013. 6. Tarumoto N, Sujino K, Yamaguchi T, et al. A first report of Rothia aeria endocarditis complicated by cerebral hemorrhage. Intern Med. 2012;51:3295–9. 7. Holleran K, Rasiah S. Atypical thunderclap headache. Case report presented to the 2nd international congress on neurology and epidemiology. Neuroepidemiology. 2012;39:177–283. 8. Falcone EL, Zelazny AM, Holland SM. Rothia aeria neck abscess in a patient with chronic granulomatous disease: case report

Please cite this article in press as: Nicodemo AC, et al. Rothia aeria endocarditis in a patient with a bicuspid aortic valve: case report. Braz J Infect BJID 346 1–4 Dis. 2014. http://dx.doi.org/10.1016/j.bjid.2014.05.001

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and brief review of the literature. J Clin Immunol. 2012;32:1400–3. 9. Verrall AJ, Robinson PC, Tan CE, Mackie WG, Blackmore TK. Rothia aeria as a cause of sepsis in a native joint. J Clin Microbiol. 2010;48:2648–50. 10. Michon J, Jeulin D, Lang JM, Cattoir V. Rothia aeria acute bronchitis: the first reported case. Infection. 2010;38:335–7. 11. Hiyamuta H, Tsuruta N, Matsuyama T, Satake M, Ohkusu K, Higuchi K. First case report of respiratory infection with Rothia aeria. Nihon Kokyuki Gakkai Zasshi. 2010;48:219–23.

12. Monju A, Shimizu N, Yamamoto M, Oda K, Kawamoto Y, Ohkusu K. First case report of sepsis due to Rothia aeria in a neonate. J Clin Microbiol. 2009;47:1605–6. 13. List of prokaryotic names with standing in nomenclature. http://www.bacterio.net/qr/rothia.html [accessed 10.03.14]. 14. Clinical and Laboratory Standards Institute (CLSI). Methods for antimicrobial dilution and disk susceptibility testing of infrequently isolated or fastidious bacteria. second ed; 2010. M45-A2.

Please cite this article in press as: Nicodemo AC, et al. Rothia aeria endocarditis in a patient with a bicuspid aortic valve: case report. Braz J Infect BJID 346 1–4 Dis. 2014. http://dx.doi.org/10.1016/j.bjid.2014.05.001

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Rothia aeria endocarditis in a patient with a bicuspid aortic valve: case report.

Rothia aeria is an uncommon pathogen mainly associated with endocarditis in case reports. In previous reports, endocarditis by R. aeria was complicate...
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